vision
Review
Pseudomyopia: A Review
María García-Montero 1, *, Gema Felipe-Márquez 2 , Pedro Arriola-Villalobos 2 and Nuria Garzón 1






Citation: García-Montero, M.;
Felipe-Márquez, G.;
Arriola-Villalobos, P.; Garzón, N.
Pseudomyopia: A Review. Vision
2022, 6, 17. https://doi.org/
10.3390/vision6010017
Received: 19 December 2021
Accepted: 1 March 2022
Published: 4 March 2022
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Vision 2022, 6, 17. https://doi.org/10.3390/vision6010017
1 Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid,
28037 Madrid, Spain; mgarzonj@ucm.es
2 Servicio de Oftalmología, Hospital Clínico San Carlos, 28040 Madrid, Spain; gemafelipe@gmail.com (G.F.-M.);
pedroarr@ucm.es (P.A.-V.)
* Correspondence: mgarc01@ucm.es
Abstract: This review has identified evidence about pseudomyopia as the result of an increase
in ocular refractive power due to an overstimulation of the eye’s accommodative mechanism. It
cannot be confused with the term “secondary myopia”, which includes transient myopic shifts
caused by lenticular refractive index changes and myopia associated with systemic syndromes.
The aim was to synthesize the literature on qualitative evidence about pseudomyopia in terms
that clarify its pathophysiology, clinical presentation, assessment and diagnosis and treatment. A
comprehensive literature search of PubMed and the Scopus database was carried out for articles
published up to November 2021, without a data limit. This review was reported following the
preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Following
inclusion and exclusion criteria, a total of 54 studies were included in the qualitative synthesis. The
terms pseudomyopia and accommodation spasm have been found in most of the studies reviewed.
The review has warned that although there is agreement on the assessment and diagnosis of the
condition, there is no consensus on its management, and the literature describes a range of treatment.
Keywords: pseudomyopia; refractive error; accommodation; accommodation spasm
1. Introduction
The qualitative definition of the term “myopia” suggested by the International Myopia
Institute (IMI) is “a refractive error in which rays of light entering the eye parallel to the
optic axis are brought to a focus in front of the retina when ocular accommodation is relaxed.
This usually results from the eyeball being too long from front to back, but can be caused by
an overly curved cornea and/or a lens with increased optical power . . . ” [1]. Considering
the term “pseudo” from the Greek pseudes, meaning false or erroneous, there are some
transient forms of myopia that are often termed “pseudomyopia”. However, pseudomyopia
cannot be confused with the term “secondary myopia”, which includes transient myopic
shifts caused by lenticular refractive index changes due to cataract [2,3], drugs [4] or
diabetes mellitus [5], during and after hyperbaric oxygen therapy [6] or after blunt eye
trauma with ciliar edema [7], or myopia associated with systemic syndromes [1,8]. The IMI
defines secondary myopia as a myopic refractive state for which a single, specific cause can
be identified that is not a recognized population risk factor for myopia development [1].
Pseudomyopia is the result of an increase in ocular refractive power due to an over-
stimulation of the eye’s accommodative mechanism [9–12]. The ciliary muscle, due either to
continual overaction or other innervation effects, does not fully relax when objects at optical
infinity are regarded [11]. Accommodation is not completely relaxed at optical infinity, and
it is abolished by complete cycloplegia refraction [13]. Therefore, ocular refractive power is
less myopic or more hypermetropic when ocular accommodation is relaxed. The difference
between cycloplegic and non-cycloplegic refraction is one of pseudomyopia’s diagnostic
signs. In fact, several authors define pseudomyopia as an apparent myopia that is acute in
onset and disappears in the eyes when they are cyclopleged [9–11,14–20].
https://www.mdpi.com/journal/vision
Vision 2022, 6, 17 2 of 16

The aim of the current study was to review the literature for qualitative evidence about
pseudomyopia as a condition where the increase in ocular refractive power is due to an
overstimulation of the eyes, without convergence spasms and miosis.

2. Methods: Literature Search

A comprehensive literature search of PubMed and the Scopus database was carried
out for articles in English published up to November 2021, without a data limit. The search
terms and queries used were (pseudomyopia OR pseudo-myopia OR pseudo myopia). This
review was reported following the preferred reporting items for systematic reviews and
meta-analyses (PRISMA) guidelines [21]. A large number of them were excluded according
the inclusion and exclusion criteria (Table 1). The titles and abstracts of all articles were
reviewed, and articles requiring a full-text review were further identified. The reference
lists of included studies were reviewed for additional articles.

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria
Pseudomyopia caused by an increase in ocular refractive power due to overstimulation of the
eye’s accommodative mechanism.
Explicit mention of pseudomyopia as the primary outcome reported.
Exclusion Criteria
Not related to subject interest.
Reported secondary myopia.
Reported pseudomyopia, but it is not the primary outcome.

3. Results
The initial search yielded 108 results after duplicates were removed. Following inclu-
sion and exclusion criteria (Table 1), after the title and abstract were reviewed, 60 of them
were selected. After the full text was revised, 22 were excluded; 11 were not related to the
subject of interest, 6 reported secondary myopia and 5 reported pseudomyopia, but not as
the primary outcome. A secondary search was carried out among the references included
in the 38 selected. This process led to 21 studies being selected and revised for the present
manuscript. Therefore, a total of 59 studies were included in the qualitative synthesis,
including 21 case reports, 11 reviews without a meta-analysis, 6 guides and 21 prospective
comparative cohort trials. The PRISMA [21] flow diagram is shown in Figure 1.

Figure 1. PRISMA flow diagram.

Vision 2022, 6, 17 3 of 16

3.1. Pathophysiology
Most of the studies referred to terms such as near work-induced transient myopia
(NITM) [22–24] and accommodation spasms [10,14,19,25–27]. Immediately after accom-
modative efforts to focus on the near, the individuals with the condition have an inability
to reduce the power of the crystalline lens rapidly and fully to focus afar. The magnitude of
NITM reported ranged between 0.2 and 0.6 D. The decay time range reported was between
6.07 and 68.2 s, and can be induced following range times of 3 to 60 min of relatively close
(a range of 0.12 to 0.25 m) near work. In addition, myopes are more susceptible to the
near work after effect than hypermetropes [24] and emmetropes [28]. In fact, some authors
reported pseudomyopia associated with excessive near work [12,22].
In addition, some authors suggest that NITM is one of the factors that contributes to
the progression of myopia, with near work being one of the most important myopigenic
environmental factors currently known [29–32]. In fact, Vasudevan and Ciuffreda showed
that residual NITM may contribute to the progression of permanent myopia [33].
Walker published several case reports in 1946 that led him to define the terms pseudo-
myopia and spasm of accommodation [10]. Before his publication, the author considered a
spasm of accommodation to be a condition found in myopes, emmetropes and hyperme-
tropes, in the young and in the middle-aged. However, he used the term pseudo-myopia
only in young myopes. After the recompilation of several cases, he concluded that the term
pseudo-myopia can be attributed to any refractive or age group. The confusion was of
the etiological origin; in fact, pseudomyopia may be due to ciliary spasms. So, an accom-
modative spasm is a condition which occurs from excessive parasympathetic stimulation
of the eye causing pseudomyopia due to ciliary muscle spasms [25]. In fact, other authors
suggested exploring the possible impact of sympathetic innervation during intense near
work [28]. In some cases, an accommodative spasm is associated with miosis and excessive
convergence of the near reflex [17,34,35]. However, it may also exist as an isolated entity
without convergence and miosis [12,14,22,25,36], which is in fact the target of the current
review.
In addition, some authors include instrument myopia [1] and night myopia [1,8,37] in
the pseudomyopia category. In dim illumination during distance viewing, a small amount
of accommodation may occur rather than be at a zero level. This is known as the dark focus
of accommodation, and is responsible for the phenomenon known as night myopia [8,37].
However, Artal et al. showed myopic shifts lower than 0.50 D that only occurred at very
low light conditions and after dark adaptation [37]. This may imply a limited practical
impact in most subjects even if the situation is under fully natural conditions.
Moreover, uncorrected hypermetropia or intermittent exotropia has been proposed for
overstimulation of the eye’s accommodative mechanism. Patients with latent hyperopia
who over-accommodate on refraction can yield a false myopic correction. This phenomenon
is of interest in the refractive surgery sections. There are some case reports that show
accommodative spasms after myopic photorefractive keratectomy [38] and laser-assisted
in situ keratomileusis procedures [39].
Large exophoria or intermittent exotropia have been described as causes of pseudomy-
opia. Due to a deficiency in fusional convergence, such patients control their exodeviation
with accommodative convergence resulting in pseudomyopia [15]. Sanker et al. reported
the case of a 22-year-old, male myopic subject with intractable accommodative spasms that
followed untreated intermittent exotropia, with no neurological abnormalities [26]. The
authors theorized that the chronic state of accommodative spasms occurred as a result of a
sustained over-accommodative response in an attempt to overcome a large angle exodevi-
ation and maintain fusion. Furthermore, Jayakumar et al. published the case of a young
29-year-old healthy male with a diagnosis of basic exotropia, where blurred vision was not
noted when uniocular visual acuity was measured [16]. The pseudomyopia was initially
missed due to inadequate binocular vision testing, but this was only speculation, as the
patient had initially presented blurred vision. The pseudomyopia persisted after strabismus
Vision 2022, 6, 17 4 of 16

surgery because of the residual angle, which he wanted to overcome by accommodative

convergence. This required the use of cycloplegic agents to abolish the spasm.
There are other causes that generate pseudomyopia: emotional/psychological disor-
ders [9,34,40–43], acquired brain injuries [18,25,36,40,44,45] and ocular traumas [22]. After
brain injury, several structures associated with the control of accommodation can be injured.
Kowal et al. published a retrospective analysis of ophthalmic manifestations in 164 patients
with a head injury, and 19% presented pseudomyopia [44]. Post-traumatic pseudomyopia
does not follow the course normally observed in functional cases [18]. In fact, London
et al., 2003 [18] reported three post-traumatic pseudomyopia cases: one that improved in
condition, another that did not improve completely and a third that did not improve at
all. One of the reported cases was not pseudomyopia. After head trauma, the shift in the
myopia evolution of the subject increased significantly, and the authors hypothesized that
trauma influenced the ocular growth mechanism in some unknown manner [18]. Chan
et al. published six new cases of post-traumatic pseudomyopia that did not manifest miosis
or esotropia. In these cases, the complaint of blurred distance vision, which was readily
rectified with glasses, was initially attributed to other neuro-ophthalmic consequences of
head trauma [36]. In addition, McMurray et al. reported the case of a 28-year-old man with
decreased visual acuity after sustaining closed head trauma in a motor vehicle accident
16 weeks earlier. The patient had a persistent accommodative spasm causing up to 5 D of
pseudomyopia [45]. Bohlmann et al. also reported a patient with an accommodative spasm
up to 9 years after head trauma, but with a lower grade of pseudomyopia, approximately
2.00 D [40]. Other authors reported one case associated with whiplash [25]. Several authors
reported different evolutions and treatments because the mechanism of post-traumatic
accommodative spasms is uncertain. Pseudomyopia after head trauma without signs of
miosis or convergence spasms has been reported for several authors, and the majority
were not resolved easily; in fact, some cases report dysfunction up to 9 years after the
trauma [40].

3.2. Clinical Presentation

The most common symptoms of pseudomyopia are a blurred and variable distance
vision and headaches [9,22,26,36]. There is a close correlation between unaided distance
visual acuity and the amount of myopia; however, this correlation is not maintained in the
presence of pseudomyopia. Fluctuations in distance visual acuity are due to fluctuations in
accommodation, and can be observed as variations in not only visual acuity, but also in the
retinoscopic reflex and, sometimes, changes in pupil diameter. Patients with an intermittent
divergent squint complain of blurred vision when seeing binocularly, due to ciliary muscle
contractions with accommodative convergence; however, this is not noted when uniocular
visual acuity is measured. This condition can confuse pseudomyopia diagnosis [16]. On the
other hand, the condition is bilateral, although there are some unilateral cases registered,
as with those presented by Peinado et al. [14], Rutstein et al. [12], London et al. [18] and
Hughes et al. [25], in which the condition was observed only when the binocular vision
was disrupted. So, it is recommended to register monocular and binocular visual acuity.
The definitive sign of pseudomyopia is significantly more minus power in the manifest
refraction than the cycloplegic refraction; this term has been named the gap refraction in
the current review, and is registered in Table 2. This additional minus power cannot be
eliminated with the standard refraction procedures used to relax accommodation at a
distance, so ocular atropination is mandatory [27].

3.3. Assessment and Diagnosis

Based on the definition of pseudomyopia as a transient form of myopia due to over-
stimulation of the eye’s accommodative mechanism [9–12], the diagnosis of the condition
can be confirmed when the non-cycloplegic refraction is more negative than the cycloplegic
refraction. Table 2 summarizes this term and the main features of the reviewed case reports.
Vision 2022, 6, 17 5 of 16

To achieve the manifest refraction, a careful subjective refraction based on retinoscopy

results is recommended to determine the lowest minus lens power that achieves the
best visual acuity [46]. In addition, cycloplegic refraction ensures an accommodation
relaxation that allows the difference between both refraction values to be known. However,
Demir et al. [47] found consistency between non-cycloplegic photoscreener measurements
and cycloplegic autorefractometer measurements in patients with pseudomyopia due to
accommodation spasms.
The recommended dosage for cycloplegic refraction is 2 drops of 1% tropicamide
or cyclopentolate given 5 min apart, and cycloplegic refraction should be performed 30
to 45 min after the first drop is instilled [48]. Some authors find both cycloplegic and
standard clinical non-cycloplegic techniques acceptable, but others consider the cycloplegic
autorefractomer technique as the gold standard [49]. However, the difference between non-
cycloplegic and cycloplegic refraction (gap refraction) is different according to the baseline
refractive status, and is a normal component of latent refractive error. Hypermetropes
demonstrated a larger gap refraction than myopes [50–52], and in the normal myopic
population without accommodative disorders, the gap refraction was <1.00 D. The gap
refraction values reported by Mimouni M et al. and Sankaridurg P et al. were between
0.36 and 0.53 D [50] and 0.28 and 0.77 D [51], respectively. These values report a normal
situation that some authors define as physiological pseudomyopia [13]. In fact, the gap
refraction summarized in the current review shows values higher than 1.00 D that are not
values of a physiological myopia, although there are some recorded under 1.00 D [18,36,38]
(Table 2).
However, this is not the only clinical sign for detecting pseudomyopia. The presence
of reduced and variable distance visual acuity, a low amplitude of accommodation for the
patient’s age, more minus power in subjective refraction than in static retinoscopy, a leading
accommodative response [18,26], fluctuations in retinoscopic findings and non-cycloplegic
refractions or pupil reflexes could suggest a diagnosis of pseudomyopia, and indicate that
a cycloplegic refraction should be performed.
In addition, an increase in the fluctuations of the refractive power of an eye with
negative spherical aberrations is another possible clinical sign [22,53]. Shetty et al. re-
ported the role of aberrometry in a case report on an accommodative spasm, after myopic
photorefractive keratectomy identified an internal defocus on aberrometry [38]. In this
case it is interesting to observe that the gap refraction is not clinically relevant; however,
the symptoms of the patients were resolved in cycloplegic conditions when the internal
defocus was reduced.
Ninomiya et al. also investigated changes in the spherical aberration of eyes with
an accommodative spasm, presenting two case reports. Their results demonstrate that
the excessive accommodative tone in eyes with an accommodative spasm is manifested
objectively by negative spherical aberrations [22]. On the other hand, Artal et al. showed
that spherical aberration does not play a significant role in night myopia [37].
Ocular examinations should include an assessment of extraocular movements and
an orthoptic exam to identify convergence excess or spasms characterized by intermittent
episodes of variable esotropia [9,14,17,34,54] or large exophoria [15,16,18,26]. A detailed
orthoptic evaluation should be performed in all cases of an accommodative spasm before
assuming that it is idiopathic [26].
It is important to discard organic processes, so some authors [12,16,19,35] recom-
mend a neurological assessment with neuroimaging tests. In addition, the history for
psychological triggers or stressors is important to consider [34] to investigate a possible
neurotic/hysterical disposition [26,41,42].
In summary, it is important to carry out a detailed examination under cycloplegia
because this is a key baseline data point for the diagnosis of pseudomyopia. In addition,
some authors [14] reinforce this test to avoid errors in the diagnosis of slight myopic
hypercorrections which frequently occur, and to avoid promoting accommodative spasms
and myopia progression.
Vision 2022, 6, 17 6 of 16

3.4. Treatment
The first step would consist of selecting management on the basis of etiology, if
any is found [14]. The definitive treatment remains problematic because, in many cases,
the etiology of the condition is unknown. However, the goal of treatment is to relax
accommodation and eliminate pseudomyopia. When the etiology of a problem is not well
understood, authors suggest looking for solutions in lower hierarchical branches. The most
extreme management methods were reported by McMurray et al., involving the removal
of the apparatus that is responding to the disrupted control of the neural input i.e., a clear
lens extraction [45]. McMurray et al. reported the case of a 28-year-old man with decreased
visual acuity after closed head trauma sustained in a motor vehicle accident 16 weeks
earlier. Several structures thought to be associated with the control of accommodation
were injured. The patient had a persistent accommodative spasm causing up to 7.0 D of
pseudomyopia. As the patient’s pseudomyopia did not appear to resolve spontaneously
and his rehabilitation was unable to progress because of the visual symptoms, it was
decided to remove the lens and thereby stop the accommodative response, providing a
stable baseline for a refractive correction [45].
The rest of the literature reviewed chooses less invasive treatment alternatives such as
cycloplegic agents [14,16–18,22,25,26,36,38–40], plus lens additions for near work during
cycloplegic treatment [14,17,18,20,36], prescriptions of manifest [18,25,36,40,55] or cyclo-
plegic refraction for distance [36], base-in prisms [11,16,20,26,54,56] and vision therapies
designed to relax accommodation [18,26] and improve fusional vergence ranges [17].
The most frequent pharmacological treatment is the utilization of cycloplegic drugs.
This treatment option started with Bohlmann and France [40] in 1987, and is still in use
today. Table 3 summarizes the historical evolution of the application of treatments, from the
oldest to the most current. The inhibition of ciliary muscle contractions through muscarinic
receptors endeavors to alter accommodative spasms. The most widely used drug is 1%
cyclopentolate [16,17,22,38] and 1% atropine [14,17,18,25,40], but a defined regime has not
been established. Some authors reported the use of 2% or 5% homatropine [18,26,36], and if,
after a period of time, the drug was not effective in relaxing accommodation, the medication
was switched to 0.25% scopolamine [18].
Due to the fact that there is a link between accommodation and convergence, the
relaxation of convergence is used as a means of treatment for inducing the relaxation of
accommodation [11]. This treatment may either take the form of orthoptics or base-in
prisms [11,16–18,20,26,56]. In fact, this strategy was the first applied in patients, from
1928 [20] to 1956 [11] (Table 3). In 1928, Shaffer described a method to reduce accommoda-
tion and convergence to zero while the patient was viewing an object at near point. First, he
placed a base-in prism to reduce the convergence to zero, and then the plus lens was added
to reduce accommodative demand [20]. In 1930, Padman reported several cases in which
the base-in prism was used to relax accommodation in an office training session and in the
habitual glasses of the patients [56]. Other authors may even warrant the prescription of
base-in prisms later if pseudomyopia recurs after cycloplegics are stopped [16].
Based on the premise that performing near-visual tasks for a prolonged time strains the
ciliary muscle and may cause abnormalities in the accommodative function of a lens, Takada
et al. investigated the visual-acuity-improving effect of a device utilizing far-stereoscopic
videos [57,58]. The authors found significant increases in distance visual acuity in a group
exposed to alternately repeating, negative and positive accommodation-viewing 3D videos,
compared to the near-visual task group.
Accommodative training in post-traumatic pseudomyopia has been reported by some
authors, but it is not clear if the normalization of the accommodative response was due to
this type of exercise or the pseudomyopia was resolved spontaneously [18]. Other authors
include accommodative and vergence training in the management of pseudomyopia as-
sociated with binocular disorders [17,26]. Shanker et al. applied accommodative training
before surgical treatment to recovery motor fusion [26], and Laria et al. reported a case of
Vision 2022, 6, 17 7 of 16

pseudomyopia associated with a convergence spasm where visual training was applied
after botulinum toxin treatment of the medial rectus [17].
Furthermore, near additions in bifocals to reduce the amount of accommodation have
been used since 1928 [20] up to nowadays [14] (Table 3). Its application is shown in cases of
esophoria associated with pseudomyopia [54], and Ciuffreda et al. suggested that in clinical
practice, relatively high-powered near point lenses should be prescribed [23]. Nevertheless,
they suggested revising the magnitude of the prescribed near-vision lens due to its effect
on the near phoria via the AC/A ratio, as well as revising the patient’s compensatory
near vergence ranges to preclude iatrogenically-induced blur, diplopia or more general
asthenopia [23].
In the management of pseudomyopia, the revising authors combined the plus lens
additions for near work during cycloplegic treatment, so the subjects restore their functional
near vision [14,17,18,36].
An overcorrection of minus lenses is not a good strategy to resolve accommodative
spasms; however, some authors reported the prescription of minus lens non-cycloplegic
refractions as a supportive measure to reduce distance blur [18,25,36]. The prescription of
cycloplegic refractions for distance has been reported in one case report, but the patients
did not support the blurred vision and the strategy was changed to the prescription of a
non-cycloplegic refraction [36].
Others authors had studied the effect of massage and acupuncture therapy in young
pseudomyopia samples (5 and 16 years) during the 3 to 18 month period [59]. They con-
cluded that combination therapy reported better effects in the treatment of pseudomyopia
than massage therapy only. In fact, the published total effective rate of 92.2% in the treat-
ment group (massage plus acupuncture) was greater than the 82.8% in the control group
(only massage). However, during the treatment, the patients were encouraged to conduct
more outdoor physical exercise, see more green plants and avoid poor eye-care habits.
These recommendations were not monitories, so there could be bias in this study. Regarding
neurotic/hysterical patients, minus lens may be prescribed initially for immediate relief [9],
although emotional therapy is recommended.
Attempts to break ciliary spasms through myotic drugs, cycloplegics with positive
lenses or vision therapy, or by giving supportive measures such as prescribing minus lenses
or multifocal intraocular lens implants in a refractory case, may be undertaken, but the
clinician and patient should be aware of the guarded prognosis [18].
Vision 2022, 6, 17 8 of 16

Table 2. Summary of the clinical features of the reviewed cases reports.

Author Non-Cycloplegic Cycloplegic Rx Gap Refraction

Sex Age Symptoms/Signs Diagnostic Test Dx/Etiology Treatment After Treatment
Year Rx (D) (D) (D)
VA Pseudomyopia
Non-cycloplegic Rx Unilateral LE
RE + 0.75 − 0.25 ×
Rutstein, Cycloplegic Rx accommodative
Blurred distance RE plano 180 RE 0.75
Marsh-Tootle Female 27 Orthoptic exam spasm Not treatment Not reported
vision in LE LE −5.00 LE + 0.75 − 0.50 × LE 5.75
2001 [12] Accomodative response associated with
180
Funduscopy excessive near
Slit-lamp exam work
Blurred distance VA RE −2.00 Pseudomyopia
Resolved
vision after a Non-cycloplegic Rx LE −3.00 Accommodative
Ninomiya et al. RE plano RE 2.00 Cyclopentolate 0.1%, SA
Male 12 head/eye Cycloplegic Rx SA spasm
2003 [22] LE plano LE 3.00 2 drops/day RE: 0.020 µm
trauma soccer Slit-lamp exam RE: −0.107 µm associated with
LE: 0.031 µm
ball SA * LE: −0.112 µm eye trauma
Pseudomyopia
VA RE −11.25 RE −3.50
Accommodative
Non-cycloplegic Rx LE −5.00 LE −3.00
Ninomiya et al. Blurred distance RE 7.75 spasm
Female 37 Cycloplegic Rx SA SA Not reported Not reported
2003 [22] vision LE 2.00 associated with
Slit-lamp exam RE: −0.075 µm RE: 0.027 µm
excessive near
SA * LE: −0.048 µm LE: 0.022 µm
work
VA
Non-cycloplegic Rx
Pseudomyopia
Cycloplegic Rx Atropine 1% daily
Monocular Unilateral RE
Peinado et al. Orthoptic exam (15 days) and +3D
Female 10 decreased of RE −6.00 RE +0.50 RE 6.50 accommodative Resolved
2019 [14] Papillary and macular near-vision
vision spasmIdio-
OCT spectacles in RE
pathic
Neurophysiological
studies
VA
Non-cycloplegic Rx
Cycloplegic Rx
Blurred distance Pseudomyopia
Orthoptic exam Far vision minus
Hughes et al. vision in RE following a
Female 34 Funduscopy RE −3.50 Not reported lens Not resolved
2017 [25] after a whiplash whiplash type
Slit-lamp exam Atropine 1%
injury sustained injury
Neuro-ophtalmology
exam
MRI
Vision 2022, 6, 17 9 of 16

Table 2. Cont.

Author Non-Cycloplegic Cycloplegic Rx Gap Refraction

Sex Age Symptoms/Signs Diagnostic Test Dx/Etiology Treatment After Treatment
Year Rx (D) (D) (D)
VA Cyclopentolate 1.0%,
Non-cycloplegic Rx 2 drops/day
Cycloplegic Rx Pseudomyopia Atropine 1%, 1
RE −9.75 − 0.25 ×
Laria et al. 2014 Headaches and Orthoptic exam RE +0.75 RE 10.50 Esotropia, drop/day and
Female 8 65◦ LE −7.75 − Resolved
[17] blurred vision Funduscopy LE +0.75 D LE 8.50 spasm of the near-vision glasses.
0.75 × 65◦
Slit-lamp exam near reflex Botulinum toxin in
Neuro-ophtalmology the medial rectus
exam Visual therapy
RE −0.50 × 165
RE −0.75 − 0.50 ×
Blurred distance VA LE −0.50 × 20◦
165◦
vision and Non-cycloplegic Rx Internal defocus Pseudomyopia
Shetty et al. LE −0.50 × 20◦ RE −0.75 Cyclopentolate 1%, 3
Female 33 headache after Cycloplegic Rx RE:0.142 µm (86% Accommodative Resolved
2015 [38] Internal defocus LE plano drops/day
one month PRK Slit-lamp exam decreassed) spasm
RE: 1.019 µm
for myopia Aberrometry † LE:0.230 µm(36%
LE: 0.366 µm
decreased)
VA
Severe headache
Airiani S, Non-cycloplegic Rx RE −2.25 − 0.50 ×
after RE plano RE 2.25 Patient lost to
Braunstein RE Female 41 Cycloplegic Rx 170◦ Pseudomyopia Cyclopentolate 1%
undergoing LE +0.75 LE 0.75 follow-up
2006 [39] Slit-lamp exam LE plano
LASIK surgery.
Funduscopy
VA Homatropine 2%, 2
Non-cycloplegic Rx Pseudomyopia drops/day for 10 AS resolved, but
Shanker et al. Headaches and RE −10.00 D RE −2.25 RE 7.75
Male 22 Cycloplegic Rx Accommodative days after exotropia
2012 [26] blurred vision LE −10.00 D LE −1.50 LE 8.50
Orthoptic examMEM spasm Accommodative intermittent
Funduscopy training
VA Bilateral Blurred vision
Squint and RE plano
Cycloplegic Rx Not reported Basic exotropia lateral rectus after strabismus
blurred vision LE plano
Orthoptic exam recession surgery
Jayakumar et al.
Male 29
2012 [16] VA
Blurred vision Non-cycloplegic Rx RE −2.00 − 0.50 × Cyclopentolate 1%, 3
RE plano RE 2.25
after strabismus Cycloplegic Rx 90◦ Pseudomyopia drops/day Not reported
LE plano LE 2.75
surgery Orthoptic exam LE −2.75 Prisms
NRA
Vision 2022, 6, 17 10 of 16

Table 2. Cont.

Author Non-Cycloplegic Cycloplegic Rx Gap Refraction

Sex Age Symptoms/Signs Diagnostic Test Dx/Etiology Treatment After Treatment
Year Rx (D) (D) (D)
VA
Non-cycloplegic Rx
Bohlmann BJ, Blurred distance Cycloplegic Rx Pseudomyopia
RE −1.50 RE 0.25 RE 1.75 Atropine 1% and Resolved after 9
France TD 1987 Female 19 vision after Orthoptic exam after a closed
LE −1.50 LE 0.25 LE 1.75 bifocals years
[40] trauma Neuro-ophtalmology head trauma
exam
MRI
VA
Non-cycloplegic Rx Pseudomyopia
Blurred distance
Cycloplegic Rx RE −1.50 RE +0.50 Accommodative
London et al. vision after RE 2.00 Accommodative
Female 15 Orthoptic exam LE−1.50 − 0.50 × LE + 0.25 − 0.25 × spasm Resolved
2003 [18] closed head LE 1.75 rock exercises
MEM 175◦ 180◦ associated with
trauma
Neurophysiological head trauma
studies
Accommodative
VA Pseudomyopia
rock exercises Partially
Non-cycloplegic Rx Accommodative
Atropine and resolved
Cycloplegic Rx spasm
London et al. Blurred distance RE −2.75 RE −0.50 RE 2.25 near-vision Eventually he
Male 25 Orthoptic exam associated with
2003 [18] vision for a year. LE −2.50 LE −0.25 LE 2.25 spectacles required far
MEM Parinaud’s
Far vision minus vision minus
Neurophysiological syndrome
lenses lenses
studies Exotropia
Strabismus surgery
VA
Blurred and Non-cycloplegic Rx Partially
Pseudomyopia
variable Cycloplegic Rx RE −1.50 − 1.00 × Homatropine 5% resolved
Accommodative
London et al. distance vision Orthoptic exam 175◦ RE −0.25 RE 1.25 Scopolamine 0.25% She required
Female 36 spasm
2003 [18] after closed head Neuro-ophtalmology LE −1.75 − 1.25 × LE −0.25 LE 1.50 Bifocal glasses +2.00 pharmacologic
associated with
trauma.Pupillary exam 157◦ D drops and
head trauma
asymmetry Funduscopy bifocal glasses
Slit-lamp exam
Blurred distance
vision without VA
Pseudomyopia
correction and Non-cycloplegic Rx
Unilateral LE Partially
blurred near Cycloplegic Rx Bifocal glasses
London et al. accommodative resolved
Male 17 vision with Orthoptic exam LE −2.25 LE −0.25 LE 2.00 RE −0.50 Ad +0.75
2003 [18] spasm He required
correction Accommodative LE −2.00 Ad +1.75
associated with bifocal glasses
unilateral for a response (MEM) and
head trauma
year after head amplitudes
trauma
Vision 2022, 6, 17 11 of 16

Table 2. Cont.

Author Non-Cycloplegic Cycloplegic Rx Gap Refraction

Sex Age Symptoms/Signs Diagnostic Test Dx/Etiology Treatment After Treatment
Year Rx (D) (D) (D)
RE −1.50 RE plano RE 1.50
Male 30 Manifest Rx Not resolved
LE −1.50 LE plano LE 1.50
RE −5.00 RE −3.25 RE 1.75
Male 20 Manifest Rx Not resolved
LE −5.00 LE −3.25 LE 1.75
VA
RE −1.50 − 0.75 × RE +0.75 − 1.50 ×
Non-cycloplegic Rx
93◦ 90◦ RE 1.50 Cycloplegic Rx
Male 18 Blurred distance Cycloplegic Rx Pseudomyopia Not resolved
Chan RV, Trobe LE −2.50 − 0.50 × LE +0.25 − 1.25 × LE 2.75 Manifest Rx
vision after Orthoptic exam after a closed
JD 2002 [36] 96◦ 70◦
trauma Neuro-ophtalmology head trauma
exam RE −1.00 − 0.25 ×
RE −2.50 − 0.50 ×
MRI 10◦ RE 1.50 Homatropine and
Male 17 10◦ Not resolved
LE−0.75 − 0.25 × LE 1.75 bifocals
LE −2.50
150◦
RE −2.00 RE −1.25
RE 0.75
Male 16 LE −1.25 − 0.75 × LE −0.50 − 0.75 × Manifest Rx Not resolved
LE 0.75
55◦ 55◦
Unsatisfactory
Decreased VA VA
despite a variety of
after closed Non-cycloplegic Rx Pseudomyopia
cycloplegic and Resolved
head trauma Cycloplegic Rx Accommodative
Mc Murray et al. RE 4.00 refractive VA was N5 with
Male 28 sustained in a Orthoptic exam NR NR spasm
2004 [45] LE 5.25 corrections +2.50 D reading
motor vehicle Axial length associated with
Finally, sequential glasses
accident 16 Computerized head trauma
clear lens extraction
weeks earlier tomography
was selected.
VA
Non-cycloplegic Rx
Cycloplegic Rx
Pseudomyopia
Park et al. 2021 Blurred distance Orthoptic exam RE −2.34 (SE) RE −0.26 (SE) RE 2.08 She is in
Female 33 with paradoxical Glasses −1.00 D
[55] vision after Accomodative response LE −2.50 (SE) LE 0.13 (SE) LE 2.63 monitorization
accommodation
Funduscopy
Slit-lamp exam
Biometry
Vision 2022, 6, 17 12 of 16

Table 2. Cont.

Author Non-Cycloplegic Cycloplegic Rx Gap Refraction

Sex Age Symptoms/Signs Diagnostic Test Dx/Etiology Treatment After Treatment
Year Rx (D) (D) (D)
VA
Non-cycloplegic Rx
Accommodative
Cycloplegic Rx RE −8.50 − 0.50 × RE +0.75 − 0.50 × Atropine
spasm
Nguyen et al. Painless vision Orthoptic exam 57◦ 7◦ RE 9.25 0.5%–0.1%–0.01% in Atropine drops
Female 10 associated with
2020 [43] loss in both eyes Accomodative response LE −9.25 − 0.50 × LE + 0.75 − 0.50 × LE 10.00 both eyes once discontinued
conversion
Funduscopy 153◦ 47◦ daily-10 weeks
disorder
Slit-lamp exam
Biometry
D: diopter; Dx: diagnosis; SE: spherical equivalent; NR: not reported; VA: visual acuity; RE: right eye; LE: left eye; Gap refraction: difference between cycloplegic and non-cycloplegic
refraction; OCT: optical coherence tomography; MRI: magnetic resonance imaging; NRA: negative relative accommodation; SA: Spherical aberration; MEM: Monocular Estimation
Method to measure accommodative response. * Spherical aberration measured by Hartmann-Shack wavefront aberrometer in central 4-mm zone. † Aberrometry measured by iTrace
Visual Function Analyzer; Tracey Technologies.
Vision 2022, 6, 17 13 of 16

Table 3. Historical evolution of treatments.

Author Year Cycloplegic Agents Plus Lenses Manifest Rx Prism Base in Orthoptics
Shaffer [20] 1928 x x
Padman [56] 1930 x
Hathaway [54] 1930 x
Willians [11] 1956 x
Bohlmann BJ, France TD [40] 1987 x x
Ciufreda [23] 1999
Chan RV, Trobe JD [36] 2002 x x x
Ninomiya et al. [22] 2003 x
London et al. [18] 2003 x x x x
Airiani S, Braunstein RE [39] 2006 x
Shanker et al. [26] 2012 x x
Jayakumar et al. [16] 2012 x x
Laria et al. [17] 2014 x x x
Shetty et al. [38] 2015 x
Hughes et al. [25] 2017 x x
Peinado et al. [14] 2019 x x
Nguyen et al. [43] 2020 x
Park et al. [55] 2021 x

4. Conclusions
There are various terms to define the condition that may lead an increase in ocular
refractive power due to overstimulation of the eye’s accommodative mechanism, and the
term accommodative spasm is the most cited. However, in several cases the accommodative
spasm is associated with miosis and excessive convergence as part of the near reflex, where
pseudomyopia is not the main clinical sign. Therefore, it is necessary to differentiate an
accommodative spasm with pseudomyopia, and define it as an isolated entity in which con-
vergence and miosis are secondary clinical manifestations, so that the terms pseudomyopia
and accommodative spasm are used interchangeably. The authors of the current review
suggest using the terms convergence spasm or near reflex spasm to reference cases where
pseudomyopia is not the primary sign.
The most common symptom of pseudomyopia identified in the review has been
blurred and variable vision. On the other hand, the majority of the reviewed authors
identify the significantly greater minus power in the non-cycloplegic refraction than the
cycloplegic refraction (gap refraction in the current review) as a definitive sign of pseudomy-
opia. In consequence, the ocular refractive under atropination is mandatory. However,
there are others assessments to clarify the diagnosis; the spherical aberration evaluation is
one of these, but there are few studies about it.
Due to the link between accommodation and convergence, the literature review in-
cludes a complete orthoptic evaluation and neurological assessment with neuroimaging
tests to discard organic processes. Generally, there is uniformity in the assessment and di-
agnosis of the condition; however, there is no consensus on management, and the literature
describes a range of treatments. Definitive treatment remains problematic because, in many
cases, the etiology of the condition is unknown. The literature reviewed chose treatment
alternatives such as cycloplegic agents, plus lens additions for near work during cycloplegic
treatment, prescriptions of manifest or cycloplegic refraction for distance, base-in prisms
and vision therapies designed to relax accommodation and improve fusional vergence
Vision 2022, 6, 17 14 of 16

ranges. The common goal of treatment is to relax accommodation and thus eliminate
pseudomyopia, but the strategies to achieve this are different.
This review has warned that there is agreement on the assessment and diagnosis of
the condition; however, there is no consensus on management, and the literature describes
a range of treatments.

Author Contributions: Conceptualization, M.G.-M. and N.G.; methodology, M.G.-M.; validation,

G.F.-M., M.G.-M. and P.A.-V.; investigation, G.F.-M.; resources, M.G.-M.; writing—original draft
preparation, G.F.-M. and N.G.; writing—review and editing, N.G. and M.G.-M.; visualization, P.A.-V.;
supervision, M.G.-M. and N.G.; project administration, P.A.-V. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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